Remote Claims Adjudication Specialist

Highmark Health; Yuma (AZ); Remote; USD 27,000 - 33,000; Full time

Job summary

Highmark Health is seeking a Remote Claims Adjudicator to screen, review, and finalize online and paper/electronic claims. You will determine pay/deny decisions, verify data, and coordinate with customers while upholding HIPAA and privacy practices.

Responsibilities include processing claims, resolving edits, ensuring accuracy, and maintaining records. The role requires strong communication, system navigation, and adherence to policies and procedures in a fast-paced environment.

Qualifications

• Strong verbal and written communication skills.
• Ability to take direction and to navigate through multiple systems simultaneously.
• Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
• Ability to use mathematics to adjudicate claims.
• Ability to solve problems within pre-defined methods and guidelines.
• Knowledge of operating systems specific to claim processing.
• Ability to review claims and analyze critical data.
• Reading benefits, investigating edits and making benefit determinations as required in adjusting and adjudicating most types of claims.
• Researches and finalizes claims, adjustments, inquiries and reports as required.

Responsibilities

• Receives and processes claims to include entering/verifying claims data; determines if claim information is complete and correct.
• Resolves claim edits, reviews history records and determines benefit eligibility for service. Reviews payment levels to arrive at final payment determination.
• Elevates issues to next level of supervision as appropriate and ensures a professional line of communication is maintained with internal and external customers.
• Meets all production and quality standards, ensuring timeliness and accuracy of all work given by support staff/management. Maintains accurate records, including timekeeping records and attends all required training classes.
• Other duties as assigned or requested.

Skills

Communication

System navigation

Admin procedures

Mathematics for adjudication

Problem solving

Claim processing OS

Data review

Benefits understanding

Education

High School Diploma/GED

Job description

Highmark Health is seeking a Remote Claims Adjudicator to screen, review, and finalize online and paper/electronic claims. You will determine pay/deny decisions, verify data, and coordinate with customers while upholding HIPAA and privacy practices.

Responsibilities include processing claims, resolving edits, ensuring accuracy, and maintaining records. The role requires strong communication, system navigation, and adherence to policies and procedures in a fast-paced environment.